Culture and Clinical Neuropsychology: Theory

How can culture affect neuropsychological function?

Neuropsychology: study of the relationship between behaviour, emotion and cognition on one hand, and brain function on the other. 

Clinical neuropsychology(NP): assessing and cognitive, emotional and behavioural function after suspecting brain damage for diagnosis and potential treatment. 

Brain damage after trauma, vascular accidents, tumours, toxicity, infections, also (neurodegenerative) diseases, or just ageing. 

NP assessment: 'imperfect index of brain function'

Physical differences: brain - Brain plasticity can be affected by: specialized skill acquisition, enrichment, deprivation, education, health, stress, correlates of differing cognitive mechanisms, experience more generally. 

Cultural neuroscience: field with focus on factors that affect biologicals and psychological processes that reciprocally shape beliefs and norms shared by groups of individuals. 

Physical differences: genetics - Core of nature/nurture interactions!

Heredity: passing on characteristics from parents to children based on genetic material. Although about 99% of genes are fixed, 1% differs across individuals. Genes can have effects that depend on external variables.

Epigenetics: environmental factors cause genes to switch on or off without modification of the DNA sequence. Chemical tags can control genes in specific cells. Epigenetic tags can result from lifestyle choices or specific experience. Some epigenetic tags are hereditary! Part of our genetics that only become available in certain circumstances.

Physiological approach is relatively new! Questions:

• How can the same physiological characteristics lead to different outcomes depending on one's culture?
• How can the same culture lead to different outcomes depending on one's physiological characteristics?

The relation between biology and behaviours may depend on the cultural meaningsof behaviours, rather than on the actual behaviours. 

How does culture influence neuropsychological assessment?

Measuring brain function: NP assessment: intelligence; memory; verbal abilities; executive functions; visuo-spatial functions; attention; syndrome-related combinations; general batteries. The scores will be compared to normative data, sometimes with correlations for age or education level. 

Culture and NP assessment: Normative data based on very limited subsample WEIRD patients: which is partial and biased. 

There are several thousands of cultures, and over 6800 language spoken! Relative differences may vary. Biggest commonality is driven by schooling, science and technology (useful information spreads fast!)  

Why would culture affect NP assessment?

Values and meaning: no general agreement on merit responses (what is the right response): eg in the Raven's, do you go for aesthetics or for rules? Attitudes, eg are animals pets or food. 

Modes of knowing: individual task vs collective endeavour: why would it matter what I know when I'm part of a collective?

Conventions of communication: interaction: one-way questions, authority; and the type of questions (both in content and way of asking).

Patterns of abilities: Culture prescribes what should be learned, at what age, and by which gender. Results in culture-specific clusters of skills or abilities that 'belong' with a stage of life or role. Tests need to be appropriate for subject's learning opportunities and contextual experiences. 

Cultural values: culture dictates what is or is not situationally relevant and significant, or even appropriate. Based on values that are not necessarily shared! 

• One-to one testing relationship with a stranger 
• Background authority: why follow orders? 
• Best performance: why try to get a high score?
• Isolated environment: unusual social situation
• Special type of communication: unusual language 
• Speed: why trade off speed for accuracy? 
• Private, embarrassing or subjective issues 
• Specific testing materials and strategies

Familiarity

Testing situation: being tested is part of school culture! 

Attitudes that facilitate good performance: motivation, purpose

Elements used in testing: eg objects, situations, stories: animals, foods, plants, natural phenomena. 

Strategies needed to solve task: eg spelling is an artificial task in language with a phonological writing system; eg cardinal direction (north, south, east, west) not used in all cultures.

Language: Linguistic relativity: Whorfian hypothesis: language influences thought. Language use and the meaning differs with a cultural and subcultural background. Correlates strongly with education level, testing language often formal. Important to make test instructions understandable and appropriate!

Education: Accounts for up to 50% of variance in IQ tests, 0.6-38% in NP tests! Double role: increases knowledge of test content; increases familiarity with testing setting and strategies. Schooling increases test performance, smaller increases with each year of schooling. 

Illiteracy

Illiteracy: not being able to read or write 

Functional illiteracy: reading and writing is inadequate "to manage daily living and employment tasks that require reading skills beyond a basic level".

Literacy is generally higher in men than in women. 2/3 of illiterates are women. In Europe, North-America and Australia, literacy is closely tied to poverty: functional illiteracy can be high in specific groups!

Research in other countries: US, Canada, Mexico, Bermuda, Italy, Norway, and Switzerland. Investigated function: document literacy, prose literacy, numeracy and problem solving. All countries have significant numbers of people with low skills: between 1/3 and 2/3 do not attain minimum level demanded by increasingly complex knowledge economy. Especially the US and Italy show a large range in skills. Lower document literacy and numeracy also associated with poorer health. Interpreted as causing difficulties to navigate the health care system. Proportionally similar health rating between countries. 

Learning to read reinforces certain cognitive abilities, such as verbal memory, phonological awareness, and visuospatial discrimination. Illiterate individual show lower scores on: naming tasks, verbal fluency, verbal memory, visuo-perceptual abilities, conceptual functions and numerical abilities. 

Illiteracy: More difficulty copying nonsense figures or words. Concrete, real-life situations much easier to process! True for all kinds of tasks: naming, memory, visuospatial, etc. Standard test materials put illiterates at a disadvantage!

Effects of being in a minority group 

Minorities within a culture: different ethnic groups in one country; after migration (especially first-generation); groups with no country. In NP assessment, testing is approached from a majority culture perspective!  

Six potentially distinguishing variables: 

• Nationality and legality 
• Relative culture distance to majority culture 
• Relative language distance to majority language 
• Normality: how ‘strange’ is the minority culture perceived by the majority? 
• Reference group: how big is the minority group? 
• Social image: positive or negative attitudes of the majority group towards a minority group  

Necessity for specific tests and norms - Indication of functional level depends on relative scores. But: not clear hoe specific this needs to be: for each language? Cultural region? Educational level? SES level? Depends on cognitive function in question! Understanding the underlying variables is at least as important as having assess to specific norms. 

Potential psychological consequences of being a member of a minority group:

• Homesickness – tends to start after 2-3 years and recurs even after long periods of time 
• Frustration – difficulty in dealing with the environment, discrimination 
• Isolation 
• Cultural solitude – lack of understanding 
• Decreased self-esteem – perceived as foolish or childish 
• Paranoia – feeling different from everyone else 
• Anger 
• Depression 
• Feelings of failure and/or success – minor successes can be perceived as very significant, also by other group members 

Discrimination and othering - Stereotypes and prejudice can lead to discrimination, which can be a large problem in contexts where there is intercultural interaction. Discrimination can affect the acculturation process in two ways: 

1. Identity denial—questioning someone’s cultural identity because he or she does not match the prototype of the culture 
2. Stereotype threat—anxieties about one’s group’s negative stereotypes lead one to confirm those stereotypes 

Discrimination has a range of negative effects on (mental) health, including High blood pressure; Heart problems; Low birth weight; Depression; Somatization; Risky behaviours such as smoking and alcohol use. 

Discrimination is very hard to study. It can be very subtle (othering). Incidents may not always be remembered or interpreted as discrimination. Effects may be moderated by coping and social support. Still an active research field, but many studies now point in this same direction of discrimination as a health risk. 

Summary part 1 - Neuropsychological assessment aims to provide an index of brain function. Physical differences may emerge based on hereditary and experiential factors. Culture can affect NP assessment in multiple ways: Patterns of abilities, cultural values, familiarity, language, education. Illiteracy affects the development of cognitive abilities. Being a member of a minority group can affect various aspects of well-being: Discrimination and other affect mental and physical health. 

Culture and Clinical Neuropsychology: Practice - clinical aspects

Implications for clinical practice

Neuropsychological practice in a multi-cultural society              Social aspects and care needs

MCI and dementia: how to diagnose?                                         What are the obstacles? 

Prevalence in different cultural groups                                      Solutions: culture-fair screenings 

Aging, prevalence of MCI and dementia

Aging - Cognitive functions decline with age. Not all! Memory and executive functions deteriorate more than vocabulary and world knowledge. Risk of mild cognitive impairment (MCI) and dementia increases with age.  

MCI - Mild cognitive impairment: Cognitive changes that are serious enough to be noticed, but not severe enough to interfere with daily life or independent function. Most common subtype of MCI first presents as memory impairment. Progression to dementia in 10 to 15% of afflicted persons per year. MCI as a precursor for dementia.  

Dementia: Umbrella term for symptoms caused by neural disorders, especially cognitive symptoms. Most common causes of dementia:

• Alzheimer’s disease: 50-80% 
• Vascular dementia: 20% 
• Dementia with Lewy bodies 15% 
• Frontotemporal dementia 5% 

Each have own most prominent symptoms, all interfere with everyday activities. Data come from Western sample! 

How do we screen for dementia? - MMSE: Mini-Mental Screening Exam (Maximum score=30, dementia is indicated for scores below 24) --> screening, not diagnosing! Kinds of items: orientation to time and place; naming; registration (responding to prompts); attention and calculation; recall; repetition; complex command (figure). 

DSM 5 name for dementia: Major neurocognitive disorder 

Obstacles to good diagnosis

Prevalence - MCI prevalence = 3.0 - 19.0%, with a risk of developing dementia of 11-33% within 2 years. Dementia prevalence = 5.4 - 6.4% (≥60 years). Not the same everywhere! Related to wealth! Higher prevalence MCI and dementia described for immigrant populations in USA and UK 

More dementia in poorer countries: the predictions are that the proportion of people with dementia will increase under low- and middle-income countries.  

Migrant groups in the Netherlands - In the Netherlands, 11.1% of the population in 2010 consisted of migrants (8.5% from outside the EU). Turkish, Moroccan and Surinamese people make up 65% of all non-western immigrants in NL (i.e. born abroad to foreign parents). First-generation non-western immigrants are aging: 4% of population in 2013, to 15% in 2039. Native Dutch older group grows a bit less fast: 18% to 28%. Older immigrants in the US show a higher prevalence of risk factors for dementia. Diabetes, cardiovascular disease, obesity, smoking, hypertension, high cholesterol, low SES.

Care experts - Among European dementia experts, 64% find it more challenging to assess dementia in patients from ethnic minorities. Reported problems include: Language proficiency (88%); Presentation of symptoms (84%); Educational level (84%); Lacking assessment tools (68%); Lacking cultural knowledge (44-56%). 

Over- and underdiagnoses - Accurate diagnosis: High sensitivity(good true detection) and high specificity(low false detection). 

Findings from Denmark: Belief: dementia is underdiagnosed in migrant groups; Finding: in general health care, immigrant groups show different rates of diagnosis than native Danish. Turkish, Pakistani and Ex-Yugoslavian groups (no difference!). Finding: Age effect: overdiagnosis for younger people (<60y) and underdiagnoses for older people. Belief supported, but only for the older group! 

Reasons for over and underdiagnoses? 

Differences in help-seeking behaviour 

• Stigma on illness, especially dementia 
• More inclined to solve problems within the family 
• Insufficient knowledge of dementia 

Difficulty with the health care system 

• Language barrier 
• Literacy skills 

Assessment and diagnosis 

• Language & literacy 
• Test-wiseness   

Examples of culture-fair diagnostic tool: CCD

Culture-fair diagnosis - From the first week: culture-fair testing! From the previous part: need to account for cultural values, familiarity, language, different education levels, interpretation of norms, etc 

Daily practice in a memory clinic: 

• In which province are we? (MMSE) 
• Who is our prime minister? (CST) 
• Read and follow this instruction (MMSE) 
• What is this? 

Cross-cultural dementia screening (CCD): Developed in Amsterdam, Validated in 2009, norm data from 2013. Instructions in own language; Culture-free/fair items; Nonverbal as much as possible. Domains: Memory, mental speed, executive function 

CCD tasks:

Memory: Objects test: remember objects among distractors 

• Household items shown in coloured pictures 
• Immediate and delayed recognition 

Mental speed and divided attention: Dots test: connect objects in order of increasing numbers 

• Adjusted Trail-Making Test, looks like dominoes 
• Using black and white dominoes instead of numbers and 
  letters 

Mental speed and inhibition: Sun-moon test: cross-name pictures in own language 

• Adjusted Stroop task using only pictures 
• Takes speed and accuracy into account 

Interpreters - CCD developed in 6 languages: Dutch, Turkish, Moroccan- Arabic, Moroccan-Tarifit, Sranantongo, Sarnámi-Hindustani. Interpreters that are not family are preferred. Shameful for patient, covering up by interpreter. Native testers are ideal! Interpreters no longer covered by Dutch insurance since 2012. 

CCD evaluation- Total battery:

• Sensitivity (true detection of dementia): 85% 
• Specificity (true detection of no dementia): 89% 

(MMSE: sensitivity=76%, specificity=.83)

All subtests showed good individual sensitivity and specificity. Strongest predictors of dementia: Objects test B (delayed) and Sun-Moon test B (Interference). 

Dementia research in migrant groups - Evidence on dementia prevalence is rare in many regions 

• Denmark: Turkish immigrants show a higher prevalence of dementia than native Danish (13.5% vs 7.0%)
• Netherlands: SYMBOL study(SYstematic Memory testing Beholding OLder Migrants)

Symbol study - Aim: to assess the prevalence of MCI and dementia in community-dwelling migrants ≥ 55yrs, and to map their and their caregivers’ health care use and care needs. Hypothesis: prevalence

Overall key points

Commonalities and culture differences in: 

• Body-image - what is perceived as attractive
• Biology - weight, length and age
• Life-style and health behaviour 
• Health and medicine - views on health and illness and use of health care. 

Body and lifestyle are influenced by our culture 

Note that: Influence of culture on health is very broad and complex. In these notes only some of the relevant topics will be discussed. The main aim is to raise awareness of differences, open mind to variety and views other than those that are so standard to you that you wouldn't even think about them. Differences between individuals from one culture can sometimes be larger than those between cultures. 

Culture and Body-Image

What is universally attractive? Evolutionary psychologists suggest preferences for visual appearances have evolutionary roots. Communalities across culture in what is perceived as attractive: clear complexion, bilateral symmetry and average features. Signs that you are healthy. People are attracted to healthy mates. 

Skin signals health more directly than any other visible aspect. The cosmetics industry provides people with ways to make their complexion look clearer. People have strong aversive reactions to skin conditions. Skin conditions often associated with stigmatization. Example: 2 Nigerian girls with skin disorder were hidden to protect the other children in the family, as marriage with member of family in which the skin disorder occurs is discouraged. 

Bilateral symmetry is a marker of health. When an organism develops under ideal conditions its right and left sides will be symmetrical. Genetic mutations, pathogens or stressors in the womb can lead to asymmetrical development. On average, asymmetrical faces are views as less attractive. 

Faces with average features are more attractive than faces that deviate from average. Average features are less likely to contain genetic abnormalities and are more symmetrical. We can more easily process any kind of stimulus that is closer to a prototype than one that is further from a prototype. And easy processing is associated with a pleasant feeling that gets interpreted as attractive. 

"Average is attractive" does not apply to aspects beyond facial features. This is seen with people's weight, height, muscles, breasts and hips. For such aspects, it's often bodies that depart from average that are seen as more attractive. The kinds of body weights that are perceived to be most attractive vary considerably across cultures. 

Body-weight 

In 1951, anthropologist and psychologist concluded that heavier women were universally found to be more attractive. Eg in Western Africa, the term "fat" is often viewed as complementary. The ideal woman is overweight, which is a sign of wealth and fertility, strength and beauty. Slim people are seen as weak or ill (malnutrition and infection are major causes of death). Undeveloped countries: thinner tend to be poorer. 

In the modern West women who are unusually thin fit the ideal body weight. These ideas for thinner women have been more prevalent during the past few decades, while actual average body weights have increased. Rich countries: negative correlations between body weight and SES - thinner tend to be richer. People in non-Western cultures and non-Western immigrant groups adopt deviant Western body images: rise in anorexia and bulimia. Eg South Africa rising incidence of eating disorders: Zulu schoolgirls use laxatives and diet pills to "look less like their mums and more like western girls".  

Media: Body-image, what is normal and how we "should" look is strongly influenced by the media. Media often portray unattainable ideals, shaped by selection of 'perfect' models, cosmetics, photographers' techniques and tricks, and photoshop. Major influence on feelings of inferiority, views on self as being abnormal, not beautiful or even ugly. Leading to use of cosmetic, braces, tanning or whitening (resulting in increased risks of (skin)cancer) and plastic surgery (resulting in the risk of cutting in a healthy body --> risk of anesthesia or infections). 

Nearness and similarity 

Other factors that influence what we find attractive 

Propinquity effect:people are more likely to become friends with people with whom they frequently interact. Based on mere-exposure effect: the more we are exposed to a stimulus, the more we are attracted to it (conditioning and easy to process). Culturally universal mechanism. 

Similarity-attraction effect: people are attracted to others if they share many similarities (eg in attitudes, economic background, personality, religion, activities). Particularly strong in cultures with high relational mobility (individualist > collectivist cultures). 

Key points body-image

Features indicating good health are generally considered to be attractive. Cultural differences in views of clothing, ideal body weight and other factors. Our own body image and attraction to others is influenced by: 1) those around us, in our (sub)culture, 2) the media. We tend to like what we see near us and, depending on culture, what is similar to us.  

Culture and Innate & Acquired Biological Variations

Human biology varies across cultures.

Explanations/mechanisms:

• Innate biological differences: the result of selection pressures
• Acquires biological differences: cultural effects on one's biology, independent of genes. 

Humans, like all organisms, evolve due to selective pressures in their environments. Different environments have different selection pressures, leading different populations to evolve different traits. Most salient example of genetic variability of humans across different populations is skin colour. 

Innate Biological Variability - Skin colour 

Skin colour strongly correlates with ultraviolet radiation (UVR) that reaches different parts of the globe. Light skin allows sufficient UVR to synthesize vitamin D. Dark skin prevents over-absorption of UVR (risks of anaemia, birth defects, or skin cancer), and prevents breakdown of folic acid. Exception: Inuit (eskimos) diet rich in fish and sea mammal blubber, high in vitamin D. Skin colour is an example of geographical influences on population variation in the human genome.  

Innate Biological Variability - Culture-gene coevolution 

Cultural factors can influence genomic variation. Culture-gene coevolution: as culture evolves, it places new selection pressures on the genome, which also evolves in response to those pressures. Example: cow domestication has led to the development of a mutation that allows us to process milk (lactase persistence). 

Culture-gene coevolution can be quite indirect: Example: farming yams in Africa required the clearing of forests: standing pools of water; malaria-carrying mosquitoes; biological adaptation of resistance; associated with sickle cell anaemia. 

Acquired Biological Variability - Visual acuity 

Biological traits can also be affected by cultural practices within a lifetime. Moken young children swim underwater to retrieve seafood. They have thus developed twice the underwater visual acuity as European children. This is not a genetic adaptation - European children can do the same through training. 

Acquired Biological Variability - Obesity

What can explain the increase in obesity rates? 1) Genetics, 2) Greater reliance on high-calorie foods (eg fast food, sodas), 3) Larger portion sizes, 4) More sedentary lifestyle, 5) Suburban lifestyle-more driving, less exercise. 

Within the West, there is considerable variation in obesity rates. France had one-fifth the obesity rate of the USA, as well as less heart disease and a longer life span. Despite French food being high in fat and sugars and despite the French having higher blood cholesterol than Americans. 

French Paradox: 1) French still eat significantly less calories a day than Americans. 2) The portion sizes are also different. People eat what's given to them, portioned. Indeed, in comparison to portion sizes in France, the portion sizes in the USA are 70-80% larger and portion sizes has been continuously increasing in the USA. 3) The attitudes towards food are different: French savour their food more than Americans. 

Acquired Biological Variability - Height

For example: in the late 19th century was the average height in the Netherlands 1.69 meter tall, during the late 20th century the average height was 1.83 meter. At this point the Dutch people are the tallest, it is possible that we are now rich enough to buy a lot of foods that make us grow (dairy).

US: there is a huge inequality between the wealth between people. Not everybody is rich enough to buy healthy food. 

The economic wealth of a country has close ties with the height of its people. More wealth brings healthier diet (more vitamins and nutrients), especially at ages when growth spurts occur. Fluctuations of countries' height across time have coincided with broad societal change that have an impact on diet.  

Acquired Biological Variability - Age 

Median ages vary significantly across the globe. (The vast majority of the countries with median age of under 20 are in Africa).

This is influenced by a number of factors, such as 1) social and economic development (poverty in many African countries, Monaco is incredibly wealthy); 2) birth rates; 3) disease; 4) ongoing conflict.  

Key points Biological variations

Our biology/bodies are influenced by culture

1. Geographical influence on selection--> innate differences in eg skin colour
2. Gene-culture coevolution--> innate differences in eg lactose persistence and malaria resistance
3. Current culture(incl. wealth) --> acquired differences in eg visual acuity, obesity, height, and age. 

Culture and Life-style & Health behaviour 

Many factors influence (cultural differences in) health (behaviour): sleep, SES, stress, control, discrimination and religion

How many hours of sleep per night do you think is necessary for good health? Current guidelines suggest around 7-9 hours a night. Before electric lighting, people's sleeping cycle actually had two phases. First, people went to sleep for a few hours a little after sunset. They woke up in the middle of the night, during which they engaged in some leisurely activities. Then they slept for a few hours again until around dawn. This also depends on culture: for example: siesta, sleeping at the heat of the day. 

The recommended hours of sleep per night for infants falls within a range, 12-15 hours per night. Example: in Japan children sleep 11.5 hours a day and in New Zealand children sleep almost 13.5 hours a day. Falls within the range, so it is not wrong. 

SES: with a higher income, people are more healthy. SES associated with health via several psychosocial variables: 

1. personality characteristics: a sense of hostility and pessimism, likely due to lower school achievement in low-SES environments (which bars people from employment opportunities), leads to poorer health. 
2. cognitive resources: poverty preoccupies people with having to make difficult choices and trade-offs for survival. Example: sugar cane farmers in southern India performed better on cognitive tasks after they harvested their crops compared to begore harvesting their crops. 
3. Attitudes towards and occurrence of unhealthy habits: fast food, smoking, less exercise
4. Access to adequate health care
5. Risky jobs: toxins, workplace accidents
6. Stress 

 (Chronic) stress can affects health in multiple ways including: 

1. Stress leads people to engage in unhealthy habits 
2. Stress weakens the immune system
3. Higher blood pressure and risk cardiovascular disease

Some environments can induce more stress, for example: New York City has been shown to make people more stressed. Consider also slums in India of favela in Brazil.

Control plays a big part 

• Low SES --> low control --> poor health
• High SES --> high control --> good health

Not (just) actual SES, but also: subjective perceptions of wealth are predictive of health: 1) A sense of relative deprivation may lead to stress; 2) It is not how poor one is but rather how poor one feels that affects health. Example: Indians in poor province Kerala outlive poor African- Americans in USA, even though much lower incomes. They are likely to feel less poor because everyone around them is poor, while African-Americans compare themselves to fellow Americans. Particularly problematic in societies where there is great social inequality (which is increasing in many countries).

Ethnicity is also a factor implicated in the link between SES and health. In the United States, African Americans and Hispanic Americans have been studied extensively in terms of their health outcomes compared to European Americans. 

Ethnicity, genetics vs discrimination - health 

For many causes of death, the prevalence rates for African Americans exceed those of European Americans, particularly for hypertension and heart disease, might often be attributed to SES. Notably, this particularly affects highly educated African American men – contrary to what one might expect based on research on SES and health outcomes. Genetics? Hypertension rates are actually much higher for African Americans compared to West Africans (who have comparable rates to European Americans). Discrimination, racism - stress, puts people at greater risk for hypertension, especially those with high aspirations to achieve. 

Epidemiological paradox: Hispanic Americans tend to have better health outcomes on average compared to European Americans, although they are generally of a lower SES. One explanation is that Hispanic Americans engage in healthier behaviours than European Americans: 1) Drinking and smoking less; 2) More social support from large communities; 3) High level of positive affect is a cultural norm.  

Religion

Something so meaningful to a large number of people might also be good for their health. In the Judeo-Christian scriptures, there is an emphasis on caring for the physical, body as a "temple of the holy spirit". Comparable views in other faiths. Religion might positively affect physical  health by: 1) encouraging healthy behaviour, such as no smoking, hence also less smoking; 2) increasing social support; 3) reducing stress and negative emotions. 

Religious and spiritual involvement can have a favourable impact on a host of physical diseases and the response of those diseases to treatment. Indeed, the relation between religious and spiritual involvement and e.g.,: 1) Lower prevalence coronary heart disease; 2) Lower blood pressure; 3) Better immune function; 4) Better endocrine function. Moreover, often people turn to religion to copewith illness

Religion can also have negative effects. Although religious people tend to have a healthier diet, they also tend to eat more. Might refrain from vaccination (e.g., measles). Refrain from (timely) using life-saving medication or other interventions.  

Life-style & health behaviour - Key points: Many factors influence (cultural differences in) health: Sleep, SES, Stress, Control, Discrimination, Religion. Cultural differences in life-style and health-behaviour are associated with health outcomes.

Culture and Health & Medicine

Very concept of health differs across cultures. From a western point of view, health is often conceptualized in a biomedical model, where health is seen in terms of (the absence of ) disease. Disease in turn is seen as originating from a specific and identifiable cause within, or arriving from outside, the body. Views from other cultures regard health as an imbalance between negative (yin) and positive (yang) forces in Chinese medicine, or elemental ingredients (bhutas) and waste products from food (vayu, pitta and kaph) in Indian Ayurvedic medicine. Further alternative views that diseases are due to supernatural causes, such as witches, demons, or ghosts. 

Differences in western medicine: in France, the metaphor of the body is the "terrain", whick emphasizes a sense of balance. French doctors prescribe more long rests and spa visits. Use of tonics and vitamins to strengthen the immune system. Dirt and germs can strengthen one’s terrain; thus, there is less emphasis on daily bathing. The USA metaphor of the body is a machine, threatened by external factors. American doctors are more likely to do surgery (to fix malfunctioning parts). Germs are a key threat to health. Doctors prescribe more antibiotics than anywhere else.

Views of health are shaped by culture and influence actual health and use of health care. These distinctions might seem clear-cut, but people can simultaneously hold